Provider Demographics
NPI:1629000302
Name:DIAZ, MARCO N (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:N
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:96 CAMPUS DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-885-9905
Practice Address - Fax:207-396-5600
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15173207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME037561OtherANTHEM
ME282820099Medicaid
NH30200521Medicaid
MEMM785505Medicare PIN
NH30200521Medicaid
G42368Medicare UPIN
MEP01035657Medicare PIN
MEMM7855Medicare PIN
MEMM785503Medicare PIN
MEMM785502Medicare PIN